Ward Practice Research Articles

Effectiveness of a Home-Based Counselling Strategy on Neonatal Care and Survival: A Cluster-Randomised Trial in Six Districts of Rural Southern Tanzania.

BackgroundWe report a cluster-randomised trial of a home-based counselling strategy, designed for large-scale implementation, in a population of 1.2 million people in rural southern Tanzania. We hypothesised that the strategy would improve neonatal survival by around 15%.Methods and FindingsIn 2010 we trained 824 female volunteers to make three home visits to women and their families during pregnancy and two visits to them in the first few days of the infant’s life in 65 wards, selected randomly from all 132 wards in six districts in Mtwara and Lindi regions, constituting typical rural areas in Southern Tanzania. The remaining wards were comparison areas. Participants were not blinded to the intervention. The primary analysis was an intention-to-treat analysis comparing the neonatal mortality (day 0–27) per 1,000 live births in intervention and comparison wards based on a representative survey in 185,000 households in 2013 with a response rate of 90%. We included 24,381 and 23,307 live births between July 2010 and June 2013 and 7,823 and 7,555 live births in the last year in intervention and comparison wards, respectively. We also compared changes in neonatal mortality and newborn care practices in intervention and comparison wards using baseline census data from 2007 including 225,000 households and 22,243 births in five of the six intervention districts. Amongst the 7,823 women with a live birth in the year prior to survey in intervention wards, 59% and 41% received at least one volunteer visit during pregnancy and postpartum, respectively. Neonatal mortality reduced from 35.0 to 30.5 deaths per 1,000 live births between 2007 and 2013 in the five districts, respectively. There was no evidence of an impact of the intervention on neonatal survival (odds ratio [OR] 1.1, 95% confidence interval [CI] 0.9–1.2, p = 0.339). Newborn care practices reported by mothers were better in intervention than in comparison wards, including immediate breastfeeding (42% of 7,287 versus 35% of 7,008, OR 1.4, CI 1.3–1.6, p < 0.001), feeding only breast milk for the first 3 d (90% of 7,557 versus 79% of 7,307, OR 2.2, 95% CI 1.8–2.7, p < 0.001), and clean hands for home delivery (92% of 1,351 versus 88% of 1,799, OR 1.5, 95% CI 1.0–2.3, p = 0.033). Facility delivery improved dramatically in both groups from 41% of 22,243 in 2007 and was 82% of 7,820 versus 75% of 7,553 (OR 1.5, 95% CI 1.2–2.0, p = 0.002) in intervention and comparison wards in 2013. Methodological limitations include our inability to rule out some degree of leakage of the intervention into the comparison areas and response bias for newborn care behaviours.ConclusionNeonatal mortality remained high despite better care practices and childbirth in facilities becoming common. Public health action to improve neonatal survival in this setting should include a focus on improving the quality of facility-based childbirth care.Trial RegistrationClinicalTrials.gov NCT01022788

Oxytocin should not be used to augment labour: AGAINST: the need for oxytocin is greatest in nulliparous women.

Oxytocin used inappropriately during childbirth is dangerous to both baby and mother and is related to poor decision-making and misinterpretation of fetal wellbeing. Surprisingly though, audits of the incidence, indications, benefits and complications of oxytocin in relevant groups of women are not available. Continuous, structured and standardised labour ward audit is the only way to justify labour ward practice, as randomised trials often do not serve the purpose. Differentiating between women in spontaneous labour, induced labour or those delivered by pre-labour caesarean section is key to understanding the benefits and dangers of oxytocin. Unless a standard classification system (Robson M Best Pract Res Clin Obstet Gynaecol 2013;27:297–308) is used to continuously audit events and outcomes in labour understanding both the dangers and benefits of oxytocin will remain elusive. Audit of events and outcomes in spontaneous labour, including oxytocin to augment, can only be interpreted by knowing what proportion of the relevant cohort of women have been excluded by either having been induced or delivered by pre-labour caesarean section because the relative sizes of these three groups influence the incidences of labour events and outcome within each of the groups. More importantly, all women within the cohort must be transparently accounted for in these groups. Consensus on the definition of spontaneous and induced labour is notably lacking in modern day obstetrics and therefore the use of oxytocin specifically in spontaneous labour is often random and poorly understood. The discussion on the use of oxytocin to augment labour can be limited for practical purposes to three separate cohorts of women. These three cohorts are nulliparous women, multiparous women without a previous caesarean scar and multiparous women with a previous caesarean section scar, but all with single cephalic pregnancies at greater or equal to 37 weeks’ gestation. In delivery units that implement a continuous, structured and standardised labour ward it is clear that the incidence, indications, benefits and complications of oxytocin vary significantly in the three cohorts of women previously described. In nulliparous women the need for oxytocin to augment labour is greatest, as inefficient uterine action is the most common cause of dystocia and the incidence of caesarean section varies most between different delivery units (Brennan D Am J Obstet Gynecol 2009;201:308:e1-e8). In multiparous women without a caesarean scar the incidence of caesarean section is low, very similar between units and the incidence of oxytocin should be <5%. In multiparous women with a previous caesarean scar, the main aim should be to persuade women to attempt a short labour, and if not using oxytocin in this group of women makes this safer and simpler by reducing the chance of scar rupture, then it should be encouraged. In conclusion, each unit must decide their policy depending on their own results, which means strict implementation of labour ward audit as previously described. However, not using oxytocin to augment in nulliparous women will inevitably result in an increase in prolonged labours and an increase in operative delivery. In multiparous women the arguments for using oxytocin to augment are less persuasive and oxytocin if used should be sanctioned by a senior obstetrician. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Blood transfusion in obstetrics.

Transfusion of blood and blood components is a common practice in obstetric wards but it is not without risk. The incidence of transfusion reactions varies from 4 in every hundred transfusions for non-haemolytic reactions to one in every 40,000 for haemolytic transfusion reactions. The physiological basis of blood transfusion is outlined in this article. Most of the donated blood is processed into components: packed red cells (PRBCs), platelets, and fresh frozen plasma (FFP) or cryoprecipitate. Various alternatives to blood transfusion exist and include autotransfusion, pre-autologous blood storage, use of oxygen carrying blood substitutes and intraoperative cell salvage. Despite the risks associated with transfusions, obstetricians are frequently too aggressive in transfusing blood and blood products to their patients. Acute blood loss in obstetrics is usually due to placenta praevia, postpartum blood loss and surgery related. An early involvement of a consultant obstetrician, anaesthetist, haematologist and the blood bank is essential. There are no established criteria for initiating red cell transfusions and the decision is purely based on clinical and haematological parameters, which have been discussed along with the general principles of blood transfusion in obstetrics and some practical guidelines.

The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth

BackgroundEvidence from the Birthplace in England Research Programme supported a policy of offering ‘low risk’ women a choice of birth setting, but a number of unanswered questions remained.AimsThis project aimed to provide further evidence to support the development and delivery of maternity services and inform women’s choice of birth setting: specifically, to explore maternal and organisational factors associated with intervention, transfer and other outcomes in each birth setting in ‘low risk’ and ‘higher risk’ women.DesignFive component studies using secondary analysis of the Birthplace prospective cohort study (studies 2–5) and ecological analysis of unit/NHS trust-level data (studies 1 and 5).SettingObstetric units (OUs), alongside midwifery units (AMUs), freestanding midwifery units (FMUs) and planned home births in England.ParticipantsStudies 1–4 focused on ‘low risk’ women with ‘term’ pregnancies planning vaginal birth in 43 AMUs (n = 16,573), in 53 FMUs (n = 11,210), at home in 147 NHS trusts (n = 16,632) and in a stratified, random sample of 36 OUs (n = 19,379) in 2008–10. Study 5 focused on women with pre-existing medical and obstetric risk factors (‘higher risk’ women).Main outcome measuresInterventions (instrumental delivery, intrapartum caesarean section), a measure of low intervention (‘normal birth’), a measure of spontaneous vaginal birth without complications (‘straightforward birth’), transfer during labour and a composite measure of adverse perinatal outcome (‘intrapartum-related mortality and morbidity’ or neonatal admission within 48 hours for &gt; 48 hours). In studies 1 and 3, rates of intervention/maternal outcome and transfer were adjusted for maternal characteristics.AnalysisWe used (a) funnel plots to explore variation in rates of intervention/maternal outcome and transfer between units/trusts, (b) simple, weighted linear regression to evaluate associations between unit/trust characteristics and rates of intervention/maternal outcome and transfer, (c) multivariable Poisson regression to evaluate associations between planned place of birth, maternal characteristics and study outcomes, and (d) logistic regression to investigate associations between time of day/day of the week and study outcomes.ResultsStudy 1 – unit-/trust-level variations in rates of interventions, transfer and maternal outcomes were not explained by differences in maternal characteristics. The magnitude of identified associations between unit/trust characteristics and intervention, transfer and outcome rates was generally small, but some aspects of configuration were associated with rates of transfer and intervention. Study 2 – ‘low risk’ women planning non-OU birth had a reduced risk of intervention irrespective of ethnicity or area deprivation score. In nulliparous women planning non-OU birth the risk of intervention increased with increasing age, but women of all ages planning non-OU birth experienced a reduced risk of intervention. Study 3 – parity, maternal age, gestational age and ‘complicating conditions’ identified at the start of care in labour were independently associated with variation in the risk of transfer in ‘low risk’ women planning non-OU birth. Transfers did not vary by time of day/day of the week in any meaningful way. The duration of transfer from planned FMU and home births was around 50–60 minutes; transfers for ‘potentially urgent’ reasons were quicker than transfers for ‘non-urgent’ reasons. Study 4 – the occurrence of some interventions varied by time of the day/day of the week in ‘low risk’ women planning OU birth. Study 5 – ‘higher risk’ women planning birth in a non-OU setting had fewer risk factors than ‘higher risk’ women planning OU birth and these risk factors were different. Compared with ‘low risk’ women planning home birth, ‘higher risk’ women planning home birth had a significantly increased risk of our composite adverse perinatal outcome measure. However, in ‘higher risk’ women, the risk of this outcome was lower in planned home births than in planned OU births, even after adjustment for clinical risk factors.ConclusionsExpansion in the capacity of non-OU intrapartum care could reduce intervention rates in ‘low risk’ women, and the benefits of midwifery-led intrapartum care apply to all ‘low risk’ women irrespective of age, ethnicity or area deprivation score. Intervention rates differ considerably between units, however, for reasons that are not understood. The impact of major changes in the configuration of maternity care on outcomes should be monitored and evaluated. The impact of non-clinical factors, including labour ward practices, staffing and skill mix and women’s preferences and expectations, on intervention requires further investigation. All women planning non-OU birth should be informed of their chances of transfer and, in particular, older nulliparous women and those more than 1 week past their due date should be advised of their increased chances of transfer. No change in the guidance on planning place of birth for ‘higher risk’ women is recommended, but research is required to evaluate the safety of planned AMU birth for women with selected relatively common risk factors.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Observance des pratiques professionnelles recommandées en maternité et réduction du risque de sevrage de l’allaitement maternel dans les six premiers mois de vie

The impact of maternity ward practices on breastfeeding duration remains uncertain in France. This study aimed to determine whether compliance with an increasing number of Baby-Friendly Hospital Initiative recommended practices was associated with a decreasing risk for breastfeeding cessation within 6 months of delivery. We analyzed the original data from a prospective cohort study carried out in eight maternity centers in France in 2005-2006. A pediatrician or a midwife prospectively collected data on breastfeeding initiation within 1h of birth, rooming-in 24h a day, pacifier non-use, and giving breast milk only for 908 mothers who were breastfeeding at discharge. Overall, 315 (34.7%), 309 (34.0%), 186 (20.5%), and 98 (10.8%) mothers experienced 4, 3, 2, or 0-1 maternity ward practices. The median breastfeeding duration was 18 weeks (25th-75th percentiles, 9 to >26), with 87.6% and 31.5% of mothers who were still breastfeeding by 4 and 26 weeks after delivery, respectively. After adjusting for study center and baseline characteristics, the hazard ratios of breastfeeding cessation associated with 3, 2, and 0-1 practices were 1.32 (95% confidence interval [CI], 1.06-1.64), 1.54 (95% CI, 1.20-1.98), and 1.59 (95% CI, 1.13-2.25) as compared with compliance with four practices (p for trend <0.001). Although the causal interpretation for this relationship remains speculative, these findings support interventions aimed to implement or reinforce Baby-Friendly Hospital Initiative recommended practices in order to establish prolonged breastfeeding and decrease the risk for early cessation after discharge to home.

Vital signs monitoring to detect patient deterioration: An integrative literature review.

Vital signs monitoring is an important nursing assessment. Yet, nurses seem to be doing it as part of a routine and often overlooking their significance in detecting patient deterioration. An integrative literature review was conducted to explore factors surrounding ward nursing practice of vital signs monitoring in detecting and reporting deterioration. Twenty papers were included. The structural component of a Nursing Role Effectiveness Model framework, which comprises of patient, nurse and organizational variables, was used to synthesize the review. Patient variables include signs of deterioration displayed by patients which include physical cues and abnormal vital signs. Nursing variables include clinical knowledge, roles and responsibilities, and reporting of deteriorating vital signs. Organizational variables include heavy workload, technology, and observation chart design. This review has highlighted current nursing practice in vital signs monitoring. A myriad of factors were found to surround ward practice of vital signs monitoring in detecting and reporting deterioration.

Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour.

Approximately 30% of Australian women use epidural analgesia for pain relief in labour, and its use is increasing. While epidural analgesia is considered a safe option from an anaesthetic point of view, its use transfers a labouring woman out of the category of 'normal' labour and increases her risk of intervention. Judicious use of epidural may be beneficial in particular situations, but its current common use needs to be assessed more closely. This has not yet been explored in the Australian context. To examine personal, social, institutional and cultural influences on women in their decision to use epidural analgesia in labour. Examining this one event in depth illuminates other birth practices, which can also be analysed according to how they fit within prevailing cultural beliefs about birth. Ethnography, underpinned by a critical medical anthropology methodology. These findings describe the influence of risk culture on labour ward practice; specifically, the policies and practices surrounding the use of epidural analgesia are contrasted with those on the use of water. Engaging with current risk theory, we identify the role of power in conceptualisations of risk, which are commonly perpetuated by authority rather than evidence. As we move towards a risk-driven society, it is vital to identify both the conception and the consequences of promulgations of risk. The construction of waterbirth as a 'risky' practice had the effect of limiting midwifery practice and women's choices, despite evidence that points to the epidural as the more 'dangerous' option.

Improving oral hygiene for patients.

Systematic reviews and patient safety initiatives recommend that oral hygiene should be part of routine patient care. However, evidence suggests it is often neglected in hospitals and care homes. Research recommends encouraging beliefs that support oral hygiene, and teaching nurses appropriate skills, as necessary prerequisites to implementing best practice in hospital wards. This article describes a pilot study of an educational workshop on oral hygiene. Results from the pilot study suggest that this workshop is a feasible intervention for a service-wide trial. The literature suggests that other interventions are required to complement this approach if nurses are to make oral hygiene a priority in daily patient care.

Nutritional care after critical illness: a qualitative study of patients' experiences.

The present qualitative study aimed to explore the factors influencing nutritional recovery in patients after critical illness and to develop a model of care to improve current management of nutrition for this patient group. Patients were recruited into the study on discharge from a general intensive care unit (ICU) of a large teaching hospital in central Scotland. Semi-structured interviews were carried out after discharge from the ICU, weekly for the duration of their ward stay, and at 3 months post ICU discharge. Observations of ward practice were undertaken thrice weekly for the duration of the ward stay. Seventeen patients were recruited into the study and, using a grounded theory approach, 'inter-related system breakdowns during the nutritional recovery process' emerged as the overarching core category that influenced patients' experiences of eating after critical illness. This encompassed the categories, 'experiencing a dysfunctional body', 'experiencing socio-cultural changes in relation to eating' and 'encountering nutritional care delivery failures'. The findings from the present study provide a unique contribution to knowledge by offering important insights into patients' experiences of eating after critical illness. The study has identified numerous nutritional problems and raises questions about the efficacy of current nutritional management in this patient group. Adopting a more individualised approach to nutritional care could ameliorate the nutritional issues experienced by post ICU patients. This will be evaluated in future work.

Nursing students' perceptions of patient dignity.

Respecting patients' dignity has been described as a fundamental part of nursing care. Many studies have focused on exploring the concept of patients' dignity from the patient and nurse perspective, but knowledge is limited regarding students' nursing perceptions and experiences. To explore the issue of patients' dignity from the perspective of nursing students. A qualitative study was employed with the formation of four focus groups and the participation of nursing students. Data were analysed via a thematic content analysis of the discussions. Thirty-four nursing students of a Cyprus University participated in the four focus groups. Each group was homogenous in terms of the year of study and heterogeneous in terms of clinical practice in various wards. The study's protocol was reviewed and approved by the Cyprus National Bioethics Committee. Ethical standards were followed throughout the study. Several factors that maintain or compromise patients' dignity emerged. These factors were grouped into five themes: (a) patients' preferences, verbal abuse and regarding a patient as a unique person; (b) privacy and confidentiality; (c) loss of autonomy and need for help; (d) discrimination and (e) attribution and reciprocity. Different understandings of the perceived concept of dignity and the factors that maintain or compromise patient's dignity were expressed through the eyes and the feelings of nursing students. Students highlighted the importance of promoting patient dignity as an important component of nursing care. Nurse educators can use the findings of this study in order to tailor nursing programmes to emphasise the importance of respecting patients' dignity. In addition, nurse ward managers can use the findings as means for persuading nurses to change current behaviour.

Discharge practices for the intensive care patient: A qualitative exploration in the general ward setting

To explore how registered nurses (RNs) in the general ward perceive discharge processes and practices for patients recently discharged from the intensive care unit (ICU). Patients discharged from the ICU environment often require complicated and multifaceted care. The ward-based RN is at the forefront of the care of this fragile patient population, yet their views and perceptions have seldom been explored. A qualitative grounded theory design was used to guide focus group interviews with the RN participants. Five semi-structured focus group interviews, including 27 RN participants, were conducted in an Australian metropolitan tertiary referral hospital in 2011. Data analyses of transcripts, field notes and memos used concurrent data generation, constant comparative analysis and theoretical sampling. Results yielded a core category of 'two worlds' stressing the disconnectedness between ICU and the ward setting. This category was divided into sub categories of 'communication disconnect' and 'remember the family'. Properties of 'what we say', 'what we write', 'transfer' and 'information needs' respectively were developed within those sub-categories. The discharge process for patients within the ICU setting is complicated and largely underappreciated. There are fundamental, misunderstood differences in prioritisation and care of patients between the areas, with a deep understanding of practice requirements of ward based RNs not being understood. The findings of this research may be used to facilitate inter departmental communications and progress practice development.

Surgical ward rounds in England: a trainee-led multi-centre study of current practice

BackgroundRecent guidance advocates daily consultant-led ward rounds, conducted in the morning with the presence of senior nursing staff and minimising patients on outlying wards. These recommendations aim to improve patient management through timely investigations, treatment and discharge. This study sought to evaluate the current surgical ward round practices in England.MethodsInformation regarding timing and staffing levels of surgical ward rounds was collected prospectively over a one-week period. The location of each patient was also documented. Two surgical trainee research collaboratives coordinated data collection from 19 hospitals and 13 surgical subspecialties.ResultsData from 471 ward rounds involving 5622 patient encounters was obtained. 367 (77.9%) ward rounds commenced before 9am. Of 422 weekday rounds, 190 (45%) were consultant-led compared with 33 of the 49 (67%) weekend rounds. 2474 (44%) patients were seen with a nurse present. 1518 patients (27%) were classified as outliers, with 361 ward rounds (67%) reporting at least one outlying patient.ConclusionRecommendations for daily consultant-led multi disciplinary ward rounds are poorly implemented in surgical practice, and patients continue to be managed on outlying wards. Although strategies may be employed to improve nursing attendance on ward rounds, substantial changes to workforce planning would be required to deliver daily consultant-led care. An increasing political focus on patient outcomes at weekends may prompt changes in these areas.

Are you fit to practice?

Abstract Ernie Ward practices in the US where the unacceptably high rates of mental illness led him to look closely at how vets should look after themselves in order to maximize their potential.

Incentives for improving human resource outcomes in health care: overview of reviews

To review the effectiveness of financial and nonfinancial incentives for improving the benefits (recruitment, retention, job satisfaction, absenteeism, turnover, intent to leave) of human resource strategies in health care. Overview of 33 reviews published from 2000 to 2012 summarized the effectiveness of incentives for improving human resource outcomes in health care (such as job satisfaction, turnover rates, recruitment, and retention) that met the inclusion criteria and were assessed by at least two research members using the Assessment of Multiple Systematic Reviews quality assessment tool. Of those, 13 reviews met the quality criteria and were included in the overview. Information was extracted on a description of the review, the incentives considered, and their impact on human resource outcomes. The information on the relationship between incentives and outcomes was assessed and synthesized. While financial compensation is the best-recognized approach within an incentives package, there is evidence that health care practitioners respond positively to incentives linked to the quality of the working environments including opportunities for professional development, improved work life balance, interprofessional collaboration, and professional autonomy. There is less evidence that workload factors such as job demand, restructured staffing models, re-engineered work designs, ward practices, employment status, or staff skill mix have an impact on human resource outcomes. Overall, evidence of effective strategies for improving outcomes is mixed. While financial incentives play a key role in enhancing outcomes, they need to be considered as only one strategy within an incentives package. There is stronger evidence that improving the work place environment and instituting mechanisms for work-life balance need to be part of an overall strategy to improve outcomes for health care practitioners.

Part 2: Applying the cultural web – Changing the labour ward culture

This is the second of two articles looking at cultural change in maternity services using Johnson's cultural web model (1992). Part one explored and explained the model in terms of the dominant cultural paradigm, and its analysis and potential for change ( Freemantle, 2013 ). This article demonstrates the application of the cultural web model to maternity services and its potential impact on women-centred care—specifically labour ward culture. A cultural web is developed and summarised before using the model to consider change and identify a desired culture that aligns with the Chief Nursing Officer's (CNO) ‘6 Cs’ vision for nursing and midwifery care ( Department of Health (DH), 2012 ), the Safer Childbirth report ( Royal College of Obstetricians and Gynaecologists (RCOG) et al, 2007 ) and Maternity Matters ( DH, 2007 ). For demonstration purposes, the change focus or problems are continued use of outdated, entrenched labour ward practices around the second stage of labour, which conflict with National Institute for Health and Care Excellence (NICE) (2007 ) best practice guidance and may well diminish or deny the opportunity for normal birth ( Williams, 2007 ). It recognises the fundamental part midwives and midwifery leadership plays in shaping and changing the culture of care, with particular reference to Supervisors of Midwives (SoM). Consequently, this model has the potential for widespread application throughout maternity services by improving efficiency, effectiveness and the environment of care.

Episodio aparentemente letal neonatal durante el «piel con piel». Tratamiento con hipotermia

‘Skin-to-skin’ in healthy newborn infants is currently routine practice in Spanish maternity wards. This practice has shown benefits in increasing the duration of breast-feeding and maternal bonding behaviour with no significant adverse events. Early sudden deaths and severe apparent life-threatening events (ALTE) during the first 24hours of life are infrequent, but well recognised. Risk factors during ‘skin to skin’ have been established. These events can lead to high neonatal morbidity and mortality. Hypothermia is now the standard of care for moderate to severe hypoxic-ischaemic encephalopathy and has shown to reduce mortality and neurological morbidity in children with hypoxic-ischaemic brain injury. Although there are no clinical trials that evaluate hypothermia after a severe ALTE, neonates who suffer it should be considered for this treatment. We present a case of a healthy newborn who had an ALTE during skin-to-skin with his mother and was treated with hypothermia.

Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study.

BackgroundDelirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery.MethodsWe adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data.ResultsAwareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier.Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices.ConclusionsAlthough our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly.Study registrationISRCTN65924234

An Antibiotic Prescription Induces Resistance at the Individual Level More Than the Group Level

To the Editor: An unnecessary antibiotic prescription may be viewed as a time bomb that may detonate in the recipient as a Clostridium difficile or antibiotic-resistant infection in subsequent months. Antibiotic utilization selects multidrug-resistant bacteria in both the individual and the facility.1,2 Many practitioners view an antibiotic prescription as a benefit to the individual at the expense of the group. However, an unnecessary antibiotic prescription hurts the INDIVIDUAL. The intensity of the damage and disruption of bacterial flora may be greater in the individual who received the antibiotic than at the group level, according to data from a hospital ward and Scottish general practice.3,4 This is an important risk-benefit consideration when contemplating antibiotic therapy for an individual. For example, Rotjanapan et al5 found that 11 (12%) of 96 residents who received an antibiotic for suspected urinary tract infection (UTI) developed C difficile colitis within 3 weeks of treatment. Inpatient quinolone therapy in the preceding 30 days increased the odds that a symptomatic UTI was caused by a quinolone-resistant organism 16 times.6 Quinolone therapy during the prior 6 months increased the odds that a febrile UTI was caused by a quinolone-resistant organism 17.5 times in outpatients.7 Trimethoprim/sulfamethoxazole prophylaxis for 1 month in postmenopausal women increased resistant Escherichia coli in the stool from approximately 20% to 85%.8 Of interest, a recent study found that antibiotic treatment of asymptomatic bacteriuria in young women increased the risk of subsequent symptomatic UTI 3 times. Antibiotic treatment in this situation apparently replaced relatively benign colonizers with more virulent bacteria.9

Tratamento em saúde mental no modelo manicomial (1960 a 2000): histórias narradas por profissionais de enfermagem

História oral temática, desenvolvida de 2010 a 2011. Objetivou descrever a vivência de profissionais de enfermagem no tratamento ao portador de transtorno mental no modelo manicomial (1960-2000). Os dados foram coletados mediante entrevista semiestruturada realizada com dois enfermeiros e quatro auxiliares de enfermagem, num hospital psiquiátrico do Paraná. Os dados foram analisados e apresentados em categorias de acordo com a proposta de análise temática. Os colaboradores relataram como tratamentos dispensados ao portador de transtorno mental, terapia medicamentosa, choque cardiazólico, insulinoterapia, eletroconvulsoterapia, entendida como importante recurso para controle da agitação, uso de cubículos e celas fortes como prática comum nos hospitais psiquiátricos, praxiterapia como ocupação. Discorreram, ainda, sobre lençol de contenção, camisa de força, e contenção no leito por faixas de tecido de algodão. Embora muitos destes tratamentos estejam em desuso e sejam criticados, eram os disponíveis e utilizados no período estudado.

Evaluation of somatic health care practices in psychiatric inpatient wards

Evaluation of somatic health care practices in psychiatric inpatient wards